MEDICARE: TENNESSEE VALLEY UROLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	MC0000012896	TN
2	208800000X	Urology Physician	012896	TN

General Provider Information

NPI Number	:	1881605509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TENNESSEE VALLEY UROLOGY PC

Provider Business Mailing Address
First Line	:	103 STATION DRIVE
Second Line	:	BUILDING 4
City	:	MARYVILLE
State	:	TN
Zip	:	37804-4190
Country	:	US
Telephone Number	:	865-982-7540
Fax Number	:	865-981-1682

Provider Business Practice Location Address
First Line	:	103 STATION DRIVE
Second Line	:	BUILDING 4
City	:	MARYVILLE
State	:	TN
Zip	:	37804-4190
Country	:	US
Telephone Number	:	865-982-7540
Fax Number	:	865-981-1682

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEVEN R MYNATT
Credential	:	M.D.
Telephone Number	:	865-982-7540

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/09/2010

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